Infections of The Spine

Yudha Mathan Sakti

Departement of Orthopaedic and

Traumatology
RS DR Sardjito FK UGM
 In 1891 during an excavation in
Thebes, French
Egyptologist Eugne
Grbaut discovered a mummy
from the 21st dynasty (between
1077 BC and 943 BC).

The mummified body belonged

to Nespaheran, a priest of
Amun, who was between 25
and 30 years old when he died.

Osteological analysis revealed

something interesting, a
severely curved back due to
destruction of the lower
thoracic and upper lumbar
vertebrae, which researchers
believe was caused by spinal
tuberculosis.
 INTRODUCTION

Infection
invasion and multiplication of microorganisms in body tissues
that causing local cellular injury due to competitive
metabolism, toxins, intracellular replication, or antigen-
antibody response.

Classification :
Infectious route: Hematogenous, local extension, direct
inoculation
Anatomic location: Vertebral body, disc, epidural space,
subdural space, facet joint, paraspinous soft tissue
 INTRODUCTION
The most common method for bacteria to spread to
the spine is by the hematogenous route (catheters,
urinary tract infection, dental caries, intravenous drug
use)

The second most common route is local extension

from an adjacent soft tissue infection (paravertebral
abscess)

The third most common route is direct inoculation via

trauma, puncture, or following spine surgery
INTRODUCTION
 Spinal Infections

1. Pyogenic infection
2. Post operative infection
3. Granulomatous infection
- Tuberculosis, etc
 Pyogenic Infections

Lumbar 50% thoracic 35% and Cervical 7%

Symptoms:
Back pain associated with
General symptoms of infection (Increased
Temp, Malaise, etc)
Back Stiffness
late: deformity & neurologic involvement.
 Pyogenic Infections

Bacterial Etiology :
Staph. Aureus (50%)
E. Coli
Proteus
Klebsiella Ozaenea
Staph. Epidermidis
 Pyogenic Infections

1. Disc narrowing (10-14 days)

2. ESR , CRP , WBC
3. Blood culture
4. MRI
5. T 99, G 67, Scan
6. C-arm guided biopsy
7. Surgery: Debridement
Exc. biopsy & culture
 AS 61 years old male;
Pyogenic spondylitis L3-4,

6 weeks Fr-Grade D
 Post Operative Infection

1% for lumbar discectomy

6% for instrumented fusion
Staph. Aureus & S. Epidermidis
Peri operative antibiotics
Sterile Techniques

Management
Early debridement, Large continuous drainage, 6 weeks, until
sterile
 Tuberculous Spine

According to WHO, November 2010, one third of the world's

population is infected with the TB bacillus.

The incidence of new TB cases in 2009, was 9.4 million most

of which occurred in the South-East Asia region

Extra-pulmonary tuberculosis is unknown, however, it is

quoted to be between 5% to l0%
 Patophysiology

The tubercle bacilli tend to lodge in highly vascular

areas such as the spine.

Vascularity + scarcity of phagocytic cells in this area;

make it a favourable environment for tuberculosis
modes of presentation include:
Patophysiology
1. The "central type" of
vertebral body disease and
"skipped lesions" in the
vertebral column is usually due
to the spread of infection along
Batson's plexus of veins.

2. Typical "paradiscal" lesions

are considered to be caused by
the spread of disease via the
arteries

3. The "anterior type" of

involvement of the vertebral
bodies seems to be due to the
extension of an abscess beneath
the anterior longitudinal
ligament and the periosteum,
stripping the periosteum from
the front and sides of the
vertebral bodies.
 Risk factors
for tuberculosis of the spine?
Certain factors define the high-risk population and should
raise suspicion Patients from countries with a high
incidence of tuberculosis, such as Southeast Asia, South
America, and Russia, are considered high risk.

Patients who live in confinement with others, such as

homeless centers and prisons, are also at risk.

Elderly adults, chronic alcoholics, patients with AIDS, and

patients with a family member or a household contact with
tuberculosis are additional high-risk groups
immunocompromised
 Clinical Presentation
Usual symptoms of anorexia or fever
malaise, fevers, night sweats, and weight
loss

Backache (in children should be regarded

as pathological unless and until proved
otherwise)

Abcess formation

One of common mode of presentation is

development of a gibbus (80% of patients
with spinal involvement have some sort of
detectable kyphosis at the time of
presentation)

Neurologic involvement
MRI Pre Op Post Op
Clinical Pre Op Post Op
 Laboratory exam
ESR The erythrocyte sedimentation rate is usually elevated

A positive Mantoux test can be observed

(may be negative in almost 20 per cent patients with
active disease if the disease is disseminated, or if the
patient is immunocompromised

Positive sputum of TB

The enzyme-linked immunosorbent assay +(ELISA) has a reported

sensitivity of 74% with extrapulmonary tuberculosis and a very high
sensitivity of 96%, against the mycobacterial antigen

Immunocompromised assessment HbSAg + HIV test

 Radiologic Exam

Local status of the spine

Chest x ray

MRI

CT Scan

Bone scan
 Definitive diagnosis
Find the microorganism in the site of infection

biopsy of the spinal lesion itself, which should be

tested for AFB
MANAGEMENT
^-^ Thank you